Abstract

Background

Home hemodialysis is common in New Zealand and associated with lower cost, improved
survival and better patient experience. We present the case of a fully trained home
hemodialysis patient who exsanguinated at home as a result of an incorrect wash back
procedure.

Case presentation

The case involves a 67 year old male with a history of well controlled hypertension
and impaired glucose tolerance. He commenced on peritoneal dialysis in 2006 following
the development of end stage kidney failure secondary to focal segmental glomerulosclerosis.
He transferred to hemodialysis due to peritoneal membrane failure in 2010, and successfully
trained for home hemodialysis over a 20 week period. Following one month of uncomplicated
dialysis at home, he was found deceased on his machine at home in the midst of dialysis.
His death occurred during the wash back procedure performed using the “open circuit”
method, and resulted from misconnection of the saline bag to the venous end of the
extracorporeal blood circuit instead of the arterial end. This led to approximately
2.3L of his blood being pumped into the saline bag resulting in hypovolaemic shock
and death from exsanguination.

Conclusions

Despite successful training, critical procedural errors can still be made by patients
on home hemodialysis. In this case, the error involved misconnection of the saline
bag for wash back. This case should prompt providers of home hemodialysis to review
their training protocols and manuals. Manufacturers of dialysis machinery should be
encouraged to design machines specifically for home hemodialysis, and consider distinguishing
the arterial and venous ends of the extracorporeal blood circuit with colour coding
or incompatible connectivity, to prevent occurrences such as these in the future.